Dr. Michael Fish: Welcome to Cancer Newsline, a
podcast series from University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer
research, diagnosis, treatment and prevention providing the latest information
on reducing your family's cancer risk. I'm your host Dr. Michael Fish, I'm the
chairman of the Department of General Oncology and today we're talking with Dr.
Damon Vidrine, associate professor of behavioral
science and Dr. Ellen Gritz, professor and chair of
behavioral science. Welcome and congratulations on your study showing that
counseling via cell phone helps smoker with HIV/AIDS quit and this research was
recently published online in clinical infectious diseases and I would tell you
that the topic of tobacco use is much on our mind at MD Anderson Cancer Center
after this year's ASCO meeting where we learned that 44 million smokers are
still out there in the United States and I was wondering why you decided to
conduct this study in an HIV/AIDS population and I wonder Dr. Vidrine if you can tell us how this got going.

Dr. Damon Vidrine: Sure. This study is actually the, the latest in the long
line of research that we've been conducting starting and, we believe 1999, this
study was informed by the, the previous research and basically we've observed
incredibly high rates of smoking in the HIV positive population, rates that
range anywhere from 45 to 70%, so two to three times higher than in the general
US population. It's also a population that suffers from the adverse effects of
smoking much more so than the general US population. So only responds to
antiretroviral treatments but also the traditional smoking related diseases
such as lung cancer, head and neck cancer.

Dr. Michael Fish: Well Dr. Gritz why is there such
a big group of smokers in this population? What is it about the population that
enriches them for this?

Dr. Ellen Gritz: Well that's a really interesting question Dr. Fish and I
think it has multiple answers. First of all, many of the individuals who are
affected with HIV/AIDS are in the lower socioeconomic classes which tend to
have much higher smoking rates than those who are more highly educated and are
in higher financial status categories. Secondly, many of these individuals are
substance users. In addition to tobacco, they use alcohol, they use other
substances and many have high rates of depression and other mental disorders
and those are traditionally and especially now conditions that are associated
with very high rates of smoking. So they all go together in a synchronistic
type of way and I think I'd like to add to Dr. Vidrine's
earlier response that one our, my close colleagues
Dr. Roberto Arduino who is a professor of infectious
disease at the UT Health Science Center and Medical School has been our
collaborator in this study and it was through conversations with him and myself
many years ago that we learned and mutually discovered that the patients whom
he was treating had these very high rates of tobacco use of smoking and that's
when we decided to embark on this collaboration which Dr. Vidrine
was a part of from the very beginning.

Dr. Michael Fish: Well so when you take the approach of trying to improve the
quit rates with smokers, tell me about how that's ordinarily done in typical
population say at cancer centers and whether your approach here was similar or
different.

Dr. Damon Vidrine: Sure. Most of the treatments are based on the public health
service guideline. It's a big collection, it's a meta
analysis basically that has been updated several times over the years,
but the treatments consist of evidence based counseling, in our case we use
cognitive behavioral treatment as well as pharmacotherapy such as nicotine
replacement therapy, Zyban, Gentex,
so what we did when we were coming up with our treatments were to, to look at
the literature, see what worked for other populations, but then we dove a lot
deeper. I mentioned some of our previous where much of these efforts were
designed to understand the barriers at place within the HIV positive
population. Dr. Gritz mentioned a few such as the
substance use, the, the alcohol use and the psychiatric co-morbidity, but we
also found basic barriers such as lack of phone service, household instability
that's a population that moves around a lot, so expecting and also a population
that depends on public transportation. So where many treatments might rely on
smokers to come to a central location for treatment, it wasn't really feasible
with the HIV positive population, so we had to understand these barriers that
lack of phone service, lack of transportation to come up with our idea and
that's when we settled on cell phones.

Dr. Michael Fish: That makes sense. When I think about some of the barriers,
I also think about cost of getting treatment and, and also maybe peer pressure
when there is enough of the people around you that are acculturated to smoking.
Are those issues in this population?

Dr. Ellen Gritz: Very much so. So when we talked about the issue of cost, we
actually gave them our participants the cell phones preloaded with calls, so we
made them available to them for free treatment in a sense and we called them
proactively again to stimulate motivation and willingness to engage with the
counselor. There's a great deal of peer pressure, there still is a great deal
of tobacco use and other substance use in the population which is a barrier not
only to quitting but to staying quit which is part of what we learned in our
study. You've mentioned before the cancer center I think we need to point out
that in the general population, individuals are usually healthy, they have more
economic freedom, they have other kinds of support systems, both personally and
socially and in this population individuals are much more challenged on all
levels both medically and socially and so the most support and this, this our
intervention relied heavily on social support through the peer counseling to
try to stimulate the desire to quit and to stay quit and the same kinds of
issues arise in the cancer patient population which we're not talking about
today but which we have a very strong and intensive program here at MD
Anderson.

Dr. Michael Fish: Dr. Vidrine did the age of this
population tend to be a bit younger than the general population or what were
there any specific age related aspects?

Dr. Damon Vidrine: No, for this trial, this treatment trial we had an average
age, I believe it was in the mid 40s and that's
pretty much what you see in most smoking cessation studies. So even though
there might a popular perception of, of HIV positive individuals being a bit
younger, it's really an ageing population with, with the advent of effective
antiretroviral, it's a population that's living longer and longer and I'd
believe that we saw that in our data.

Dr. Michael Fish: Fair enough. Now Dr. Gritz when I
think about cell phone interventions, I'm always thinking about texting and so
many people choose to text. Was that a component of this study or was it just
using the cell phone for voice exchange.

Dr. Ellen Gritz: So at the time that this particular study was funded, I'm
not sure the texting even existed. You know how fast the electronic world is
developing, so we were, we call this a novel intervention, it was even in the
title of our grant application and it worked very well, but now we see with
texting and all sorts of smartphones of various kinds that we have to be even
more novel and faster, so the next generation studies that Dr. Vidrine is heading up those will have all those features.

Dr. Damon Vidrine: And in fact some of them are already underway, so we have
an ongoing study that will compare the voice based intervention that we did in
the past with the purely text based intervention. So one of our questions will
be to see if health literacy which appears to be limited in this population to
see if that will impact the effectiveness of the text based intervention, but
again we're, we're working on those answers right now.

Dr. Michael Fish: Good to hear. Well, Dr. Vidrine
when I think about successful quit rates, we learned that it tends to be 6 or
7% at one year and in your study you did a lot better than that at least early
on. Why do you think this was effective, this counseling via cell phone?

Dr. Damon Vidrine: Well, you, you say effective and we did have a nice
treatment effect, but we did see those steep relapse rates that you just
mentioned, so by six months and a year we were down there below 10%. I believe
early on we were able to increase the social support, we were able to provide
coping skills to bring about quit attempts and get people to quit at least
temporarily and I think that we see that in other smoking cessation trials as
well, maybe not population based trials but at least in clinical trials we see
this. I think our steep relapse curves really speak to all of these other
problems that are present in this population that Dr. Gritz
mentioned before. And I believe that the next generation of interventions will
have to actively take on the depression, the substance abuse and the alcohol
use to really find a, a way to sustain the cessation rates over and beyond a
three month period.

Dr. Ellen Gritz: I also want to add that this is very typical for all
smoking cessation clinical trials that the highest quit rates are found at
short-term follow up and then there is a decline over time in terms of relapse,
but as Dr. Vidrine pointed out, we feel that our
population is at much greater risk of relapse because all of the personal and
social and other barriers that we have discussed in addition to which this next
time in future trials we want to be able to assure that all participants have
active access to pharmacotherapy and nicotine replacement or whatever other
agents we may design because those also help deal with the craving and the
nicotine addiction part of the behavior and this is a chronic relapsing
disorder. We are asking a lot of individuals to quit and stay quit when in the
general population permanent cessation sometimes takes up to 14 attempts.

Dr. Michael Fish: Well that seems awfully challenging because the cost of
the, those interventions is not trivial and I know that in the county health
systems and in other systems it's not necessarily part of the care plan for
these more expensive interventions and I wonder whether you, Dr. Gritz would think that, that changing healthcare
environment and pay for performance type approaches could come into play to
improve the investment in some of the effective smoking cessation treatments.

Dr. Ellen Gritz: We think this is a critical point and a major point because
while you may say that the treatment is expensive, smoking cessation treatment
is perhaps the single most cost effective intervention in medicine that I know
of today. I can't site you the, specific dollar amounts, but compared to
mammography or many other prevention interventions, smoking cessation has huge
cost savings in terms of disease incidents and disease treatment treating lung
cancer and treating other cancers, heart disease, pulmonary diseases which are
chronic conditions cost hundreds and thousands if not millions of dollars
versus you might talk about a few hundred dollars to help somebody quit smoking.

Dr. Michael Fish: Well Dr. Vidrine this is exciting
work and I know a lot people would be interested to know what the implications
of this work might be for the general public not just HIV population. What have
we learned that the general public can take home?

Dr. Damon Vidrine: Well I, I think some of the big lessons that we've learned
is no matter how underserved the population is, no matter what the competing
healthcare needs are such as we observed in the HIV positive population that
people who smoke, want to quit smoking and they prioritize that and they
participate in smoking cessation trials, they can quit, they want to quit and
they want to keep it rolling, they keep in trying to quit, so I think that
among the most positive outcomes of this study was the just positive
endorsement that we received from our participants and I think with that's
often the case among smokers, smokers want to quit, so I, I found that very
reassuring.

Dr. Ellen Gritz: And I think this is a very important take home message to
the general public that very often people want to give up on individuals who
are facing serious diseases and they say their life isn't going to be that long
or they don't really want to quit, they have so many other problems, they're
not thinking about their tobacco, their tobacco is the only thing that helps
them and reinforces them to keep going, but it isn't true and we learned in one
of the those earlier studies that Dr. Vidrine
mentioned too that there was very high motivation to enroll and seek treatment,
that wasn't one of our feasibility trials. And again I'm going to make the same
statement with regard to cancer patients whom we often think oh once they have
cancer what's the point in their stopping smoking, but we've learned here in
the tobacco treatment program, a very parallel lesson that people really do
want to stop and when we emphasize to them, it's the single most important
personal thing that you can do to participate in your healthcare. They become
more empowered and, and it becomes very rewarding to work with them under those
circumstances.

Dr. Michael Fish: That's such as critical point and I'm so glad you're able
to make that and I was, I was shocked to learn that only 29% of NCI trials
assess tobacco use and I wonder whether the trial list have just not had that
point well understood.

Dr. Ellen Gritz: Thank you Dr. Fish for bringing that up because I was one
of the authors on that paper and what we did was we assessed almost 160 NCI
supported clinical trials that are operated through the clinical trials
cooperative groups and it was to our great shock to see that 79% of those
trials made no assessment whatsoever, so 21% did, 79% didn't and mostly it was
to ask whether people smoked at the beginning of the trial and mostly that was in
trials that had to do with smoking related cancers, none of them assessed
nicotine dependence, none of them assessed follow up of smoking status
throughout the trial and this is very important because smoking has adverse
effects on treatment, on cancer treatment and on medical outcomes and on
survival, quality of life, I could go on and on even though this particular
interview is about HIV.

Dr. Michael Fish: Well I think you made the point very well and I wonder for
the HIV trials, do they assess tobacco better? How is that going Dr. Vidrine?

Dr. Damon Vidrine: It's another good point and we've seen quite a change in
the years that we've been doing this. When Dr. Gritz
and I first started work and Dr. Arduino first
started working on this topic, we found a lot of resistance about assessing
smoking, about doing anything about it, I think recent data has really
indicated just how bad smoking is for individuals with HIV. There was some big
Danish cohort study that came out talking about the, the population attributable
risk of smoking, basically HIV positive individuals lose far more years of life
to smoking than they do HIV and when they're HIV positive and smoking it's a
synergistic relationship so it's especially bad. I believe that the, the people
who run the clinical trials and as well as treating physicians realize this
now. So we're as years ago we got resistance, now Dr. Gritz
and I probably get phone calls weekly to advise on how to assess smoking and
what we can do to, to help HIV positive patients quit, so it's been quite a
turnaround, a very positive.

Dr. Michael Fish: Well congratulations. I think things are changing and we
look forward to a new landscape in this regard. So Dr. Gritz
I wonder if you have any final thoughts about resources people should know
about or what they should anticipate for the future with this work.

Dr. Ellen Gritz: Well we are certainly continuing our research. We have a
study ongoing now at the legacy foundation, the federally qualified health
agency and we are planning continued improved efforts to boost cessation rates
to tailor and intensify the treatment to link individuals to other sources of
assistance in the community and in their health agencies and to really
normalize this behavior and to help people realize that tobacco is a seriously
addicting substance and that even individuals with any sort of chronic illness
can benefit from quitting.

Dr. Michael Fish: I want to thank Dr. Vidrine and
Dr. Gritz for being with us today. If you have any
questions about anything you've heard today on Cancer Newsline,
contact Ask MD Anderson at 1-877-MDA-6789. We're online at www.mdanderson.org
Thank you for listening to this episode of Cancer Newsline.
Tune in for the next podcast in our series.